A report issued Monday by the Orange County Grand Jury says nearly half of the deaths connected to Orange County jails could have been avoided if the sheriff’s department paid more attention to health issues. Orange County Sheriff Sandra Hutchens, who plans to retire this year, has not yet commented on the report. (Photo by Ken Steinhardt, Orange County Register/SCNG)

Nearly half of the 34 deaths at the Orange County jail over the past three years could have been avoided if the sheriff’s department and medical staff paid more attention to health issues, according to a report issued Monday by the Orange County Grand Jury.

The citizen group found that inmates sometimes didn’t get in-house medical treatment when necessary, weren’t diagnosed properly for pre-existing health problems or mental illness, and didn’t get outside medical help in a timely manner. Those issues in the jails, the grand jury wrote, increase the chances “that an inmate will not make it out alive.”

Sheriff Sandra Hutchens responded that her department is very concerned about inmate safety and avoiding jail deaths. However, she added that state law to reduce prison overcrowding has increased the number of drug-using criminals — along with their health issues — in local jails.

“Each death is tragic, but the long term health consequences of drug abuse are difficult to remedy with even the best medical care,” Hutchens said. “The lesson from this report is that efforts to combat drug addiction, drug trafficking and the root causes of drug dependency must continue.”

The report noted problems went beyond drug use.

After studying the autopsies of the 34 people who died while in custody or shortly after leaving jail, the grand jury found rampant undiagnosed illnesses, including two cases of HIV and 17 cases of Hepatitis. Additionally, the grand jury found 14 of the 34 inmates had not been tested for tuberculosis.

“Failure to detect Hepatitis B, Hepatitis C, and HIV at the Intake Release Center puts the jail population and staff at risk for these diseases,” the grand jury wrote.

The report also noted that nine of 20 inmates who received CPR suffered three or more broken ribs, a broken sternum, or damaged internal organs – an excessive rate of injury, according to American Heart Association guidelines.

It’s not clear if all the problems described in the report are worse in Orange County than in other jails.

The report did not study the death rate at other jails, or offer any statistical data to show if the death rate in Orange County jails is higher or lower than average. The county jail system is one of the largest in the nation, processing more than 50,000 bookings each year and housing more than 6,000 inmates a day.

Also, some of the medical functions criticized by the grand jury are provided by Correctional Health Services, which falls under the Orange County Health Care Agency, not the sheriff’s department.

But criticism of the sheriff’s department, which operates the county jails, isn’t unusual.

Last year, the American Civil Liberties Union and news investigations issued reports that questioned health care in the jails, violent holds used by some jailers, and, according to the ACLU, improperly housing transgender inmates.

The department also has been under federal investigation for several years. Initially, federal officials looked at Orange County jail practices following a 2006 beating death of an inmate while a deputy jailer watched the television show “Cops,” an investigation that was never formally closed. More recently, federal officials opened a civil rights investigation following court findings that some deputies were illegally using informants to help prosecutors win convictions and the description by one court that cheating among deputies and prosecutors in Orange County is “systemic.”

The department also took heat following the 2016 escape of three violent inmates from the jail, and a subsequent week-long manhunt that gained national media attention.

Most recently, sheriff officials have been criticized following the in-custody death of Danny Pham, a car thief who sometimes lived on the streets. When he was killed, Pham had been put in a cell with another inmate who previously admitted killing two homeless people.

The grand jury noted that its investigation of in-custody deaths was prompted by Pham’s case. The report found that 19 of the 34 inmates who died while connected to Orange County jail over the past three years had been assigned to cells with violent offenders or people carrying contagious diseases.

The report figures to become a political issue in the November election. Orange County Undersheriff Don Barnes is running to take over for Hutchens, who is retiring at the end of this year. Duke Nguyen, a public integrity investigator for the Los Angeles County District Attorney’s Office, also is running for the job.

Barnes has said the sheriff’s department has improved conditions and protocols in the jails, and that suggestions of ongoing problems are overblown and old news.

Nguyen said Monday the grand jury report bolsters his argument that the problems in the jails aren’t a result of rogue deputies and, instead, are a result of poor management.

“This highlights the reoccurring issues within the sheriff’s department,” Nguyen said. “There is a leadership culture that is unwilling to take responsibility and make changes…The grand jury findings are not the first time we are hearing about improper management in our jails.”

The grand jury found that some of the problems could be quickly and inexpensively corrected. For instance, some of the cases in the study had missing, incomplete or unclear health records — in part because inmates withheld information. But jurors noted that medical interviews were done in the open, and that inmates might be unwilling to disclose personnel health information within earshot of other inmates.

Drug screens also are not routine, making it difficult to identify inmates entering the jail with toxins in their system.

Grand jury recommendations include:

— Using urine drug screens for all inmates as they enter the system to make a more accurate assessment of the inmate’s medical condition.

— Performing universal Hepatitis B, Hepatitis C, and HIV tests at the Intake Release Center to make an appropriate decision for treatment, vaccination, and housing.

— Require the Orange County District Attorney’s Office and the coroner to follow the standards of the National Association of Medical Examiners and require the cause of death and toxicology results for inmates who die in jail.

An earlier version of this story incorrectly suggested a 2017 ACLU report criticized the Orange County Sheriff’s Dept. of racism and homophobia.

Tony Saavedra is an investigative reporter specializing in legal affairs for the Orange County Register. His work has been recognized by the National Headliner Club, the Associated Press Sports Editors, the California Newspaper Publishers Association, the Orange County Trial Lawyers Association and the Orange County Press Club. His stories have led to the closure of a chain of badly-run group homes, the end of a state program that placed criminals in inappropriate public jobs and the creation of a civilian oversight office for the Orange County Sheriff's Department, among other things. Saavedra has covered the Los Angeles riots, the O.J. Simpson case, the downfall of Orange County Sheriff-turned felon Michael S. Carona and the use of unauthorized drugs by Olympian Carl Lewis. Saavedra has worked as a journalist since 1979 and has held positions at several Southern California newspapers before arriving at the Orange County Register in 1990. He graduated from California State University, Fullerton, in 1981 with a bachelor of arts in communication.

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